Healthcare Provider Details

I. General information

NPI: 1740362474
Provider Name (Legal Business Name): MARY W KUDLESS MSN RN CS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3834 N TAZEWELL ST
ARLINGTON VA
22207-4555
US

IV. Provider business mailing address

3834 N TAZEWELL ST
ARLINGTON VA
22207-4555
US

V. Phone/Fax

Practice location:
  • Phone: 703-241-5584
  • Fax: 703-237-4999
Mailing address:
  • Phone: 703-241-5584
  • Fax: 703-237-4999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0015000370
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: